Embryo Development, Grading and Selection Copy —
Training activity: 8

Details

Assess suitability for extended embryo culture

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Local SOPs/protocols
• Suitability for extended culture
• Benefits and risks
• Patient support and information
• Cost considerations
• Patient involvement in decision making

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to assessing whether embryos are suitable candidates for extended culture.
• Consider how the learning outcomes apply, specifically in relation to evaluating embryo quality and development and interpreting and reporting embryology results.
• Discuss with your Training Officer to gain clarity of what is expected of you in relation to the criteria and decision-making process for extended culture suitability.

What is your prior experience of this activity?

• Think about what you already know about the rationale and criteria for extended embryo culture from academic content (e.g., embryo development, morphokinetic assessment).
• Liaise with your peers to understand how different clinics may take different approaches to extended culture.
• Consider possible challenges you might face during the activity, such as interpreting morphokinetic data, assessing borderline embryos, or balancing clinical factors.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example, if the assessment of a borderline embryo requires confirmation before determining the culture strategy.
• Acknowledge how you feel about embarking on this training activity, particularly regarding making decisions that impact culture strategy.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as applying selection criteria and interpreting developmental data for extended culture.
• Identify the specific insights you hope to gain into the factors that predict successful extended development.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of embryo selection or culture decisions.
• Identify important information you need to consider before embarking on the activity, such as patient age, clinic success rates with extended culture, or the clinic’s specific SOP or guidelines for extended culture selection.
• Consult with your peers to gain an understanding of the different approaches to extended embryo culture between clinics. Some clinics may exclusively culture to blastocyst whereas others may offer cleavage stage transfer and cryopreservation. Appreciate the reasoning behind these approaches, and consider the pros and cons.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst evaluating embryo development and quality to determine suitability for extended culture?
• Are you encountering situations such as:
  • Morphokinetic data (e.g., time-lapse kinetics) conflicts significantly with the observed morphological grade, complicating the decision.
  • A critical developmental marker (e.g., specific cleavage timing) is unexpectedly delayed, requiring immediate re-evaluation of suitability criteria.
  • Technical issues with time-lapse data retrieval or analysis arise, necessitating a decision based solely on static morphological assessment.

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to integrating disparate clinical data and morphological assessment?
• Consider the steps you are taking in the moment, such as immediately reviewing the departmental SOP for resolving morphokinetic-morphology conflicts in suitability assessment, or cross-referencing the embryo’s developmental rate with clinical history.
• How are you feeling in that moment? For instance, are you finding it difficult to balance conflicting predictive data points? Is it affecting your confidence in making the final suitability decision?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying the SOP criteria to classify the embryo despite complexity? Or are you needing support because the level of conflicting data requires senior pathological review before the culture strategy can be confirmed?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective systematic review technique for integrating multiple data points (morphology, kinetics, patient factors) for embryo selection?
• Your clinic may not routinely use timelapse. Consider the pros and cons of embryo grading using standard incubation.

On action

What happened?

• Begin by summarising the key steps you took when assessing suitability for extended embryo culture.
• Consider specific events, actions, or interactions which felt important, such as how you applied the developmental criteria (e.g., cell number, symmetry, time-lapse kinetics) or how you discussed the implications of extended culture with the clinical team.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, revisiting the initial morphological assessment when the embryo showed unexpected slowing in time-lapse data.
• How did you feel during this experience, e.g., focused on integrating diverse data points (morphology, kinetics) into a single decision or stressed by the ambiguity of borderline selection?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding integrative decision-making and applying selection criteria. What strengths did you demonstrate, e.g., systematic review of all available morphokinetic data?
• What skills and/or knowledge gaps were evident, e.g., difficulty assessing the prognostic value of subtle fragmentation patterns for extended culture?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in evaluating embryo quality and development to inform clinical decisions?
• Identify any challenges you experienced, such as conflicting recommendations from clinical guidelines vs. local historical data for extended culture, and how you reacted to this. This might include needing to seek advice or clarification on scope of practice regarding final determination of culture length in complex cases, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the application of selection criteria for extended culture.
• What will you do differently next time you approach assessing suitability for extended culture, for instance, by proactively establishing a detailed comparison checklist for integrating morphological and kinetic data?
• Do you need to practise any aspect of the activity further, such as interpreting time-lapse data kinetics or key learning outcomes related to understanding human embryonic development and differentiation?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of analysing the outcomes of extended culture (e.g., blastocyst failure) or reviewing advanced predictive algorithms since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, a subsequent instance where embryos assessed as high-grade unexpectedly arrested in culture forced you to re-evaluate the rigour of initial assessment criteria and prediction models during your first attempt at this training activity.
• Considering what you understand about morphokinetic predictive value and balancing culture strategies now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your selection criteria and integration of critical developmental data based on further learning and experiences? For example, how you proactively began systematically tracking the correlation between initial day 3 assessment and eventual blastulation/pregnancy outcome to refine future decisions.
• Has discussing difficulties predicting developmental arrest or the impact of culture conditions on embryo quality with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a challenging decision where a senior embryologist overruled an extended culture decision refined your understanding of the multifactorial nature of embryo selection.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent morphokinetic analysis and outcome correlation experiences, contributed to your overall confidence and ability in determining culture strategy based on predictive quality assessment, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated skill in synthesizing morphological and kinetic data now enables you to confidently select embryos for transfer (which includes selecting against extended culture if unsuitable) during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to embryo selection criteria and prediction models? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or Specialist Embryologist immediately when conflicting morphokinetic data and morphological grade necessitates review to confirm the culture strategy.
• Looking holistically at your training journey, how has this initial extended culture suitability assessment experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to evaluating embryo quality and development to inform clinical decision? For example, how this foundational experience has supported your development in interpreting and reporting embryology results by necessitating clear justification for culture duration.

Relevant learning outcomes

#	Outcome
# 1	Outcome Evaluate embryo quality and development to inform clinical decision.
# 3	Outcome Interpret and report embryology results.
# 4	Outcome Communicate embryo grade and clinical decisions effectively with patients and the multidisciplinary team to enhance the overall patient experience.